下腰椎不同固定方式的生物力学对比研究

目的 观察下腰椎不同固定方式对腰椎稳定性的影响.方法 新鲜成人尸体下腰椎标本6具,测定L4/5节段屈伸、左右侧屈、左右旋转6个方向ROM和刚度值的变化,按5组顺序依次测试:A组(正常下腰椎标本组);B组(单侧椎板关节突螺钉固定+椎间单枚Cage);C组(单侧椎弓根螺钉固定+椎间单枚Cage);D组(单侧椎弓根螺钉联合对侧椎板关节突螺钉固定+椎间单枚Cage);E组(双侧椎弓根螺钉固定+椎间单枚Cage).结果 与A组比较,B组各运动状态ROM有减少,而刚度明显增加,差异有统计学意义(P＜0.05);与B组比较,C组各运动方向ROM与刚度,差异无统计学意义(P＞0.05);与C组比较,D组各运动状态ROM有减少,而刚度增加,差异有统计学意义(P＜0.05);与E组比较,D组各运动方向ROM与刚度,差异无统计学意义(P＞0.05);与E组比较,C组各运动状态ROM有增加,而刚度减少,差异有统计学意义(P＜0.05).结论 单侧椎板关节突螺钉固定并椎间融合器植骨方法提供了一定的稳定性,而单侧椎弓根螺钉联合对侧椎板关节突螺钉固定并椎间融合器植骨具有与双侧椎弓根螺钉固定相同的稳定性,临床上可根据病例的具体情况,如身高体质量指数、病变类型及病变节段稳定程度选择性地应用上述两种固定融合方法.     

下胸段经关节突入路椎间盘切除术对脊柱稳定性影响的观察

目的：观察下胸段经关节突入路椎间盘切除术对脊柱稳定性的影响。方法：采用新鲜成人尸体下胸椎标本（T9～L1）6具,在T11～T12节段建立4种经关节突入路椎间盘切除模型：（1）单侧关节突切除＋椎间盘摘除（ULF＋D）;（2）单侧关节突切除＋全椎板减压＋椎间盘摘除（ULF＋L＋D）;（3）双侧关节突切除＋全椎板减压＋椎间盘摘除（BLF＋L＋D）;（4）双侧关节突切除＋全椎板减压＋椎间盘摘除＋单节段椎弓根钉棒固定T11～T12,于前屈,后伸,左、右侧曲和旋转6个方向进行加载,记录100N载荷下的ROM值。将4种模型ROM值分别与完整标本的ROM值按照配对t检验比较进行统计学分析。结果：与完整标本比较,ULF＋D在旋转方向的ROM值有显著性差异,ULF＋L＋D和BLF＋L＋D在6个方向上的ROM值均有显著性差异（P〈0.05）;T11～T12椎弓钉棒系统固定后在轴向旋转和前屈方向的ROM值无显著性差异（P〉0.05）,在其他三个方向上存在显著性差异（P〈0.01）。结论：ULF＋L＋D和BLF＋L＋D对脊柱下胸段6个方向上的稳定性均有显著性影响,辅以椎弓根钉固定相应节段,能够显著恢复脊柱稳定性。     

前路单节段融合内固定治疗伴椎弓根断裂的Denis B型胸腰椎爆裂骨折生物力学研究

目的探讨前路单节段融合内固定治疗伴椎弓根断裂的Denis B型胸腰椎爆裂骨折后的脊椎生物力学稳定性。方法取6具新鲜成人尸体胸腰椎标本(T11~L3)作为正常组(A组),采用椎体切除法依次建立L1Denis B型爆裂骨折模型并行前路单节段融合内固定,分别为椎弓根完整组(B组)、单侧椎弓根切断组(C组)和双侧椎弓根切断组(D组)。通过脊柱三维运动机依次测定各组在8.0 N·m纯力偶矩下屈伸、左右侧弯及左右旋转活动度(range of motion,ROM)。结果 B、C、D组T12、L1脊柱运动单元前屈、后伸、左右侧弯ROM均显著低于A组(P0.05),D组显著高于B、C组(P0.05),B、C组间差异无统计学意义(P0.05);B、C组左右旋转ROM均显著低于A、D组(P0.05),B、C组间及A、D组间比较差异无统计学意义(P0.05)。各组间L1、L2脊柱运动单元前屈、后伸、左右侧弯、左右旋转ROM比较,差异均无统计学意义(P0.05)。结论前路单节段融合内固定治疗Denis B型胸腰椎爆裂骨折伴一侧椎弓根断裂时,在屈伸、侧弯及旋转方向能提供足够初始生物力学稳定性,而伴双侧椎弓根断裂时生物力学稳定性差。     

单枚融合器单侧钉棒内固定治疗腰椎间盘突出症并腰椎不稳

目的探讨单枚融合器单侧钉棒内固定治疗腰椎间盘突出并腰椎不稳的临床效果。方法采用椎板间扩大开窗、椎间盘切除单枚cage置入、单侧钉棒内固定治疗186例腰椎间盘突出并腰椎不稳。结果本组经0.5-5年的随访,无神经根损伤,按Macnab疗效评定标准：优176例,良6例,可4例,优良率97.8%。结论腰椎间盘突出并腰椎不稳采用椎板间扩大开窗,椎间盘切除单枚cage置入,单侧钉棒内固定治疗,具有手术创伤较小、疗效确切、有利于患者早期功能锻炼与恢复工作的优点。     

寰枢椎后路四种钉棒固定方法的三维稳定性评价

目的：评价寰枢椎后路四种不同钉棒固定方法的生物力学稳定性。方法：6具人体新鲜颈椎标本，切除齿状突及寰枢间韧带等结构制造寰枢椎失稳模型．对每具标本先后进行5种方式固定：A组（双侧C1椎弓根螺钉＋C2，3经关节螺钉）、B组（C1椎弓根螺钉＋C2侧块螺钉）、C组（C1椎弓根螺钉＋C2椎弓根螺钉）、D组（C1椎弓根螺钉＋C2椎板螺钉）；与对照组E组（Magerl螺钉．即经C1/2侧块关节螺钉）进行对比，在脊柱三维运动实验机上测量比较其寰枢椎间的屈伸、侧屈、旋转三维稳定性。结果：在前屈稳定性上，四种钉棒固定方法（A、B、C、D组）间无差异（P〉0．05）．且均优于单纯Magerl螺钉固定（E组）（P〈0．05）。在后伸稳定性上．D组与E组两种固定方法间无差异（P〉0．05），其抗后伸的稳定性较A、B、C组略差（P〈0．05）；A、B、C组三种钉棒固定方法间无差异（P〉0．05）。在侧屈运动稳定性上．D组的稳定性略差，其他四种固定方式间无差异（P〉0．05）。在旋转稳定性上，所有固定方式间无统计学差异（P〉0．05）。结论：四种钉棒固定方法都具有可靠的三维稳定性．临床应用时可以根据患者的个体解剖结构情况和术者对不同手术技术的熟悉程度进行选择。     

枢椎棘突螺钉单侧应用联合对侧椎弓根螺钉固定的有限元分析

目的分析枢椎棘突螺钉单侧应用联合对侧椎弓根螺钉固定在寰枢和枕颈固定中的生物力学稳定性。方法构建正常枢椎解剖、椎板薄和椎动脉变异椎弓根细小3种不同解剖状态下的完整上部颈椎有限元模型作为完整模型组,然后分别模拟齿状突骨折进行寰枢固定和寰椎骨折进行枕颈固定。在寰枢固定中,比较单侧枢椎棘突螺钉+对侧椎弓根螺钉+双侧寰椎侧块螺钉固定组(棘突螺钉组)和枢椎双侧椎弓根螺钉+双侧寰椎侧块螺钉固定组(椎弓根螺钉组);在枕颈固定中,比较单侧枢椎棘突螺钉+对侧椎弓根螺钉+枕骨螺钉固定组(棘突螺钉组)和枢椎双侧椎弓根螺钉+枕骨螺钉固定组(椎弓根螺钉组)。枢椎棘突螺钉分别测试水平、斜向、垂直置钉3种不同的固定技术。模拟颈椎运动,测量枕颈的屈伸、侧屈、旋转的关节活动范围(ROM)。结果在寰枢和枕颈固定中,棘突螺钉组和椎弓根螺钉组的C1~C2屈伸、侧屈、旋转ROM均较完整模型组均明显下降。在寰枢固定中棘突螺钉组C0~C2屈伸、侧屈、旋转的ROM大于椎弓根螺钉组;在枕颈固定中,棘突螺钉组C1~C2侧屈的ROM大于椎弓根螺钉组,棘突螺钉组的C0~C2旋转的ROM大于椎弓根螺钉组。枢椎棘突螺钉分别测试水平、斜向、垂直固定间有差异,但不明显。结论在寰枢和枕颈固定中,枢椎双侧椎弓根螺钉固定和枢椎单侧棘突螺钉联合对侧椎弓根螺钉组合式固定方法均具有良好的稳定性。在寰枢固定中,相对于枢椎棘突螺钉组合式固定,枢椎双侧椎弓根螺钉固定具有更好的寰枢稳定性。在枕颈固定中,枢椎双侧椎弓根螺钉固定在侧屈和旋转活动上较枢椎棘突螺钉组合式固定稳定性更好。枢椎三种棘突螺钉置钉技术间的稳定性差异并不明显。     

斜外侧椎间融合联合单侧椎弓根钉棒固定术的三维有限元分析

目的 :运用三维有限元分析法验证斜外侧椎间融合术(oblique lateral interbody fusion,OLIF)辅助单侧椎弓根钉棒固定能否为相应单一融合固定节段提供足够的椎间稳定性。方法:在健康人L3～S1节段CT扫描数据的基础上,利用Mimics、Geomagic、3-Matic软件建立L3～S1三维有限元模型,设定为正常对照组(M0),以此为基础联合使用Freeform等软件分别建立L4/5节段OLIF单纯融合固定(Stand alone)模型(M1)、OLIF辅助单侧椎弓根钉棒固定(Wiltse入路)模型(M2)、OLIF辅助双侧椎弓根钉棒固定(Wiltse入路)模型(M3)。设定500N预载荷作用于L3顶端,再施加10N·m的力矩模拟脊椎直立、前屈、后伸、侧屈及旋转等生理活动,按上述加载条件作用于M0,对模型有效性性进行验证,同时按相同加载条件作用于各有限元模型,观察各有限元模型不同工况下L4/5节段相对活动度(ROM)、椎间融合器和椎弓根钉棒应力分布状况,记录最大应力值。结果:通过与文献数据比较,本有限元模型L4/5节段ROM在不同运动状态下与前人研究结果相近,证明本模型具备有效性。4组有限元模型前屈、后伸、左右侧弯、左右旋转运动状态下ROM值由小到大排序为M3、M2、M1、M0。M2相比M0、M1能较好地控制前屈和后伸,M2的ROM相比M0前屈后伸时变化幅度分别为75.43%、85.20%,相比M1变化幅度分别为58.88%、70.39%。M3相比M2前屈和后伸时稳定性亦较好,M3的ROM相比M2前屈后伸时变化幅度分别为25.55%、25.33%。除外变化幅度差异较小的右侧弯和右旋转状态,M2较M0的ROM变化幅度远大于M2与M3之间ROM的变化幅度。M2相较M0各工况下ROM变化幅度为14.08%～85.20%,M2相较M3各工况下ROM变化幅度为16.44%～25.55%。椎间融合器应力值方面,除直立时M2应力峰值略高于M1,其余运动状态下OLIF各手术组融合器应力峰值随着附加椎弓根钉棒数量的增加而表现出一定的下降趋势,这种趋势以后伸时表现最明显,幅度变化为109.14%。钉棒应力峰值方面,M2钉棒应力峰值除右侧弯时明显低于M3,左侧弯时略低于M3,其余运动状态下其钉棒应力峰值均高于M3,二者应力差异以右侧弯和后伸时较大,M2较M3分别变化-33.09%和76.79%。三组模型钉棒及椎间融合器应力峰值均远未达到其屈服强度。结论:OLIF联合单侧椎弓根钉棒固定模型可以为相应融合固定节段提供足够的椎间稳定性。     

不同后路短节段内固定术治疗Hangman 骨折的生物力学比较

目的：测试不同后路短节段内固定术治疗Hangman骨折的生物力学性能，探讨内固定方式的选择。方法：8具新鲜C0～C4颈椎标本，按照①正常状态（对照组）；②Ⅰ型骨折C2椎弓根螺钉固定（A组）；③ⅡA型骨折C2椎弓根螺钉固定（B组）；④Ⅱ型骨折C2椎弓根螺钉固定（C组）；⑤Ⅲ型骨折C2椎弓根螺钉固定（D组）；⑥Ⅲ型骨折C2、3椎弓根侧块钢板内固定（E组）顺序在脊柱三维运动实验机上依次测试其三维运动范围（ROM），对结果进行统计学分析。结果：A组ROM值与对照组无显著性差异；B组除旋转外与对照组无显著性差异，旋转稳定性也达到了对照组的61．86％；C组与对照组均有显著性差异；D组ROM值最大，与对照组有显著性差异；E组除后伸外ROM值均明显小于对照组，差异有显著性（P〈0．05）。结论：C2椎弓根螺钉固定可使Ⅰ型Hangman骨折达到生理性固定，使ⅡA型骨折恢复较好的稳定性，不能使Ⅱ、Ⅲ型骨折获得稳定；后路C2、3椎弓根侧块钢板内固定后的三维稳定性较好，适合不稳定型Hangman骨折的外科治疗。     

单枚融合器与单钉棒系统微创术式的有限元研究

目的 探讨融合器放置方法对单钉棒固定系统各结构单元、对侧小关节应力分布的影响.方法 建立腰椎功能节段及椎弓根螺钉及融合器的三维有限元模型,将其叠加后获得融合器垂直放入及斜向放入的单侧固定TLIF术式有限元模型,加载后测试系统在前屈、后伸、左屈、右屈及左旋、右旋等各工况下融合器、螺钉、钛棒及对侧小关节应力分布情况.结果 ①融合器无论是垂直放入还是斜向放入,椎弓根螺钉的载荷分布情况无明显差异;②融合器斜向放入时,可以明显改善右侧弯及前屈状态下的对侧小关节的应力分布;③融合器斜向放入可以明显改善后伸状态下融合器及终板的应力分布;并可改善左旋状态下钛棒的应力分布.结论 在实施单侧的TLIF术式时,融合器合理的放置方式应该是斜跨中线放置,这样不仅有助于改善系统的整体应力分布,同时有助于降低终板的应力峰值,从而减小终板塌陷;并减小对侧小关节的应力载荷,降低对侧小关节紊乱和术后腰痛的发生率.     

腰椎单侧椎弓根螺钉固定的三维有限元分析

目的:建立人正常L3～L5节段三维有限元模型,分析腰椎单侧椎弓根螺钉固定融合的生物力学特性.方法:基于人正常L3～L5节段的CT扫描数据,利用Geomagic Studio 9.0、Simpleware 2.0、Abaqus 6.7软件建立人正常L3～L5三维有限元模型(INT),并在此基础上分别建立L4/5单侧椎弓根螺钉内固定加后外侧植骨融合模型(M1)、单侧椎弓根螺钉内固定加单枚融合器置入模型(M2)及双侧椎弓根螺钉内固定加单枚融合器置入模型(M3).在L3上表面施加500N预载荷,再施加10N·m的力矩模拟腰椎前屈、后伸、侧屈及旋转等生理活动,观察不同工况下L4-L5节段角位移、椎弓根螺钉及融合器应力分布情况.结果:各工况下M1、M2、M3角位移均较INT减少,M3减少最明显;除右屈和后伸外,其他工况下M2与M3的角位移减少程度相当,而M1在左、右侧屈及左、右旋转时稳定性较差.M1的螺钉应力峰值明显高于M2和M3,尤以左屈及后伸载荷时螺钉应力峰值最大,M2螺钉应力峰值高于M3.M2椎间融合器的应力峰值在各种工况下均高于M3.结论:单侧椎弓根螺钉固定不能很好地控制侧屈和旋转载荷,椎弓根螺钉承受较大的应力;附加单枚融合器置入可以重建融合节段的稳定性,明显减少螺钉的应力.     

Total cavopulmonary shunt operation for single atrium and single ventricle

A 17-year-old woman with single atrium, single ventricle, common atrioventricular valve and hemiazygous continuation underwent a total cavopulmonary shunt operation successfully. She had been cyanotic and with a heart murmur since two months of age. She was first seen at our hospital at three years of age. Catheterization, performed at the same time, had revealed pulmonary stenosis and transposition of the great arteries. At 17 years of age, catheterization was again performed, and a clinical diagnosis of single atrium, single ventricle, common atrioventricular valve and hemiazygous continuation was made. After the diagnosis was confirmed, a total cavopulmonary after ligation of the main pulmonary artery and shunt operation was performed division of the left superior vena cava, the distal end of the left superior vena cava was anastomosed to the confluent pulmonary artery. Two hours after return to ICU, extubation was done. The cardiac index was 4.36 L/min/m2 with central venous pressure of 145 mmH2O. The arterial oxygen saturation was 88.4%. After the surgery, this woman is doing well, with decreased CTR and improved exercise tolerance. Total cavopulmonary shunt can produce a marked improvement in the condition of patients with some type of complex cyanotic congenital heart disease.     

Anesthetic management of a patient with single atrium and single ventricle

A 41-year-old woman with single atrium and single ventricle at 6 weeks of gestation was scheduled for dilation and evacuation of the fetus. The PaO2 was 39 mmHg, while she was breathing room air. Dilatation of the uterine cervical canal was performed under spinal anesthesia using 2.0 ml of 0.5% hyperbaric bupivacaine one day before dilatation and evacuation of the fetus. A sensory anesthesia level of T 10-S 5 was achieved. The systolic blood pressure decreased to around 70 mmHg. On the next day, dilation and evacuation of the fetus was performed under spinal anesthesia using 1.5 ml of 0.5% isobaric bupivacaine. Sensory anesthesia level was L 1-S 5. There was no precipitous decrease in blood pressure. However, intravenous fentanyl was needed during the procedure. There was no cardiovascular or respiratory complication after anesthesia and surgery. The patient was discharged on the next day.     

单一术者机器人辅助单孔腹腔镜前列腺癌根治术学习曲线分析

目的 评估单一术者在不同时间段开展的机器人辅助单孔腹腔镜前列腺癌根治术（sp-RALP）之手术效果,探讨该手术方式的学习曲线。方法 回顾性分析南京中医药大学附属医院2020年1月至2020年12月由同一手术医师连续完成的100例sp-RALP的临床资料。按时间顺序将患者分为5组（A组即第一阶段组为第1～20例,B组即第二阶段组为第21～40例,C组即第三阶段组为第41～60例,D组即第四阶段组为第61～80例,E组即第五阶段组为第81～100例）,比较5组间的手术时间、术中出血、引流管留置时间、术后住院天数等方面的差异。结果 随术者经验例数的累积,手术时间、术中出血量均呈下降趋势,A、B两组与C、D、E三组间分别对比差异均有统计学意义（P均<0.05）,A组与B组间对比仅手术时间的差异存在统计学意义（P<0.05）,C、D、E三组间两两对比差异均无统计学意义（P均>0.05）;而引流管留置时间、术后住院天数各组间研究的差异均无统计学意义（P均>0.05）。结论 机器人辅助单孔腹腔镜前列腺癌根治术（sp-RALP）学习曲线相对陡峭,大约在40例手术经验积累之后基本...     

Management of single ventricle

The management of two cases of single ventricle is reported. Ventricular septation was undertaken in the first case with Van Praagh type-C single ventricle. In the second patient with type-A single ventricle with outlet chamber on the right side, normally placed great vessels and narrow bulbo venticular foramen, tricuspid valve was closed, converting the lesion into tricuspid atresia. The bulbo ventricular foramen was closed and right atrial-right ventricular anastomosis performed similar to Björk procedure for tricuspid atresia. Patient succumbed three days later. The problems in surgical management of single ventricle is discussed.     

Laparoendoscopic single site orchiopexy

We report a laparoendoscopic single site orchiopexy in a 2-year-old boy with a right nonpalpable testis. Diagnostic laparoscopy using a 5-mm port revealed a right intraabdominal testis. The 5-mm port site was extended to accommodate the smallest commercially available triport, and orchiopexy was performed. The operative time was 55 minutes, and the estimated blood loss was minimal. There were no complications, and surgical and cosmetic results were excellent. Laparoendoscopic single site surgery is a feasible technique for orchiopexy of the nonpalpable testis.     

New tools to study biophysical properties of single molecules and single cells

We present a review on two new tools to study biophysical properties of single molecules and single cells. A laser incident through a high numerical aperture microscope objective can trap small dielectric particles near the focus. This arrangement is named optical tweezers. This technique has the advantage to permit manipulation of a single individual object. We use optical tweezers to measure the entropic elasticity of a single DNA molecule and its interaction with the drug Psoralen. Optical tweezers are also used to hold a kidney cell MDCK away from the substrate to allow precise volume measurements of this single cell during an osmotic shock. This procedure allows us to obtain information about membrane water permeability and regulatory volume increase. Defocusing microscopy is a recent technique invented in our laboratory, which allows the observation of transparent objects, by simply defocusing the microscope in a controlled way. Our physical model of a defocused microscope shows that the image contrast observed in this case is proportional to the defocus distance and to the curvature of the transparent object. Defocusing microscopy is very useful to study motility and mechanical properties of cells. We show here the application of defocusing microscopy to measurements of macrophage surface fluctuations and their influence on phagocytosis.     

Bilateral single ectopic ureter

A case of successfully treated bilateral single ectopic ureter with a follow-up of 13 years is reported. The genesis of the incompetence of the vesical sphincter and its treatment are discussed.     

Bilateral single ectopic ureter

A case of single bilateral ureteral ectopia is presented. Patient underwent bilateral ureteral reimplantation with right ureteral tailoring, with a satisfactory result.